Basic Information
| Provider Information | |||||||||
| NPI: | 1407023328 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHELDON MEDICAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTHWEST REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 490 N 2ND ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675221 | ||||||||
| FaxNumber: | 5412675221 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 N 2ND ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675221 | ||||||||
| FaxNumber: | 5412675221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 08/14/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHELDON | ||||||||
| AuthorizedOfficialFirstName: | MELODY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SPEECH PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5412675221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | 10886 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
ID Information
| ID | Type | State | Issuer | Description | 089037 | 05 | OR | MEDICAID | 047063 | 05 | OR | MEDICAID |